What does it take to become and remain a good therapist?

I become concerned about the current emphasis on marketing in younger therapists to the relative exclusion of how one grows into becoming a good therapist; and in continuing to grow.  As a psychologist who is expert in marketing has been quoted to me recently, marketing means doing good work and then talking about it.  But how does one get to be doing good work?

Some therapists are successful at building good practices fairly quickly if they are attractive, gregarious and sound professionally convincing.  But without the depth of understanding of oneself and the ability to empathize with a variety of people of different ages, backgrounds, and issues, the work will not be effective, let alone deeply satisfying.    Clients will terminate prematurely and  referrals decline when when referring professionals get negative reports about the lack of growth to those whom they made referrals.

Of course the success of one’s practice depends, at least partially, on the type(s) of clients the therapist works with and the preferred therapeutic modality.  If the modality is short-term treatment, then being technically proficient may be adequate.   But if the therapist is working with longer-term clients who are looking for and able to profit from a more personality-changing, growth-oriented orientation, then the demands on the therapist can be much more challenging.

In order to be successful doing personality-changing therapy, one needs the following:

  • Experience working with a wide variety of clients with different kinds and degrees of problems.  Even if one works only with individual children,  adolescents or adults; couples; families; or groups; she is going to see a variety of clients.  They will have different degrees of distress, goals in therapy, and socioeconomic backgrounds; vary in amount of past therapy experience, optimism and presence of growth resources;  and in intellectual level.  This means that the therapist will have to be flexible and vary how he is treating and relating to the client.

  • A thorough theoretical orientation:   The majority of the research indicates that it doesn’t matter which theory of therapy the therapist prefers, but rather that  she be well grounded in it.   This contributes to the therapist’s confidence in her abilities and results in the client’s greater confidence that growth will occur.  I also think the type of therapy the therapist practices should be an orientation with which the therapist is comfortable.  For example, an intellectual, more aloof, therapist might be more suited to a psychoanalytic modality; a more practical, down-to-earth therapist might be more suited to CBT, EMDR or behavior therapy; while a more emotionally-oriented,  person who needs interpersonal contact might be more comfortable with a relationally-oriented therapy such as Client-centered or Gestalt therapy.

  • Flexibility:  But what is most important for therapeutic success is that the therapist sense how the client needs him  to be with the client and have the flexibility to provide that, whether it be formal and “professional” or warm and casual.  The therapy outcome research has shown that most clients do better in therapy if the therapist is warm and caring, but there is also research showing that a sub-set of clients actually prefer therapists who are more formal.  These are the clients who tend to feel easily intruded upon and can feel threatened if the therapist is too friendly.

  • Ongoing consultation: The therapist should be involved in ongoing consultation.  Even though I have been practicing for over 35 years, I still find myself experiencing impasses with certain clients and find great value, insight and professional growth from consultation groups of which I am a part.  Hearing other perspectives from these contacts with other therapists also help to keep my work vital, exciting and effective.

  • Self-awareness:   One needs a deep awareness of one’s own personal strengths and weaknesses.  This usually requires having been in extensive personal therapy and not, in my opinion, the brief therapy that some graduate programs require. Without the awareness of one’s own issues, both resolved and unresolved, the therapist cannot work effectively  with a wide variety of clients.   It also helps therapist  to experience what it’s like being in the position of the client.   I once had an analyst who said that being a psychotherapy patient is inherently vulnerable, even potentially humiliating, since the therapist is in a position of control and power, while the client is in an exposed position.  I think this implicit power differential is something therapists should always keep in mind.

  • Empathic abilities:  Empathy as Carl Rogers defined it, is the ability to put oneself into the psychic shoes of his or her clients and understand them, particularly emotionally, without losing one’s own perspective.   This means being open to one’s own emotional life, particularly problematic emotions such as shame, fear, guilt, envy, and hatred.   Of course one must also be able to be empathic about positive affects the client may be experiencing, reflecting those back to him at the appropriate time and building on those affects.  I myself became aware some years ago that I was more attuned to my clients’ negative thoughts and feelings than to their positive ones, and had to change that tendency.   A wake-up call for me was a depressed, pessimistic engineer client who travelled one weekend to Alamogordo, New Mexico, where the first atom bomb was exploded.  He was excited during our next session telling me about his pleasure at seeing the huge crater the bomb had made.  I was very concerned at the time about the possibility of a world-wide nuclear conflagration, was noncommittal in my response and he then looked crestfallen.  I realized that he needed my mirroring of his joy and that I could be happy that he had had what, for him, was a rare positive experience rather than judging the source of the happiness.

  • Openness to new experience:  The therapist needs to take the open attitude that no matter how many years of experience she or he has, there is still much new to learn.  Each client is unique and, in an important sense, a brand new psychotherapy needs to be created to work with that client. Instead of trying to make the client fit the therapy, it is making the therapy fit the client

  • Dealing effectively with negative feelings:  The therapist will inevitably have negative judgments about his or her clients.  These are often, unfortunately, the result of the process of diagnosis and often mask negative emotions therapists have about their clients  For example, years ago I read a study in which psychotherapists  were administered  Q-sorts of statements about two imaginary people.  One sort was for Borderline clients; the other was for People I Dislike.  There was an almost perfect correlation (in the .90’s) of the two sortings.  This does not mean that therapists should deny their negative feelings toward certain clients.  Used thoughtfully, they can be the source of important information about the client and are detrimental to the therapeutic  process only as long as the therapist doesn’t own them.  If they are un-owned, they can limit the process of exploration and empathy and result in missing the client and premature termination or a therapeutic impasse.  But if they are owned–e.g., “I am feeling frustrated and helpless with this client” rather than “She is passive-aggressive and trying to sabotage my efforts with her.”  The therapist then can explore the negative enactment that is occurring between her and the client and  there is the possibility for movement in the therapy. Because I admitted to myself that I had negative feelings toward the engineer I discussed above (he was working for a defense contractor), I was able to notice his disappointment in my reaction to his telling me about his trip to Alamogordo.  We were then able to explore the whole sequence of interchanges between us, relate it to a lack of  the lack of  mirroring by his parents, his hope for reparative mirroring from me, and his resultant disappointment.   The experience ended by being positive for both of us.  If I hadn’t been willing to own my own negative emotions, we wouldn’t have been able to create this positive, growthful outcome.

  • Dealing effectively with positive feelings:  Therapists must learn to deal effectively with their own feelings of fondness for certain clients and the affectionate feelings, often of a sexual nature, clients may have for them.  The issue of sexuality in the consulting room is, in my experience, one of  the most problematic but potentially most growthful aspects of intensive  therapy.  Knowing how to work with clients who become dependent on their therapists is a related area of potential growth,  but also of potential conflict and discomfort for both parties.  I will discuss this issue more fully in a future post.

  • Recognition of psychotherapy as a dyadic relationship:   I believe that the therapist must realize she or he is part of what Robert Stolorow, a leading psychoanalytic theorist, calls an intersubjective field, i.e., that the therapeutic relationship is one where there is a system of mutual reciprocal influence.  This is very different from the view of most therapeutic schools that the therapist is an objective observer and that what the client brings to the therapeutic hour is a function only of the client’s persona.  It means that who the client actually is as a person in the consulting room is what she or he brings to the situation, particularly the encoded beliefs about the world and his or her place in it, and how the therapist is subjectively experienced.  And the converse is also true:  who the therapist actually is in the room is what he or she brings to the therapeutic relaltionship in terms of past experience and beliefs that have been encoded, including how the client is subjectively experienced.  This is a thoroughgoing contextual view of humans and implies that they are fluid, interdependent processes rather than “things” with rigid self-other boundaries.  It represents an antidote to the subject-object split we make in Western culture (and in much of psychology) and is recognition of the deep relatedness of human beings.